Vertebral augmentation-related Clostridium septicum osteomyelitis

Abstract

We present a case of vertebral osteomyelitis following multiple vertebral augmentations in a patient with an insidious presentation. Vertebral augmentation (kyphoplasty and/or vertebroplasty) is a minimally invasive procedure that has become a fairly common and highly effective method in treating compression fractures. A large majority of patients that undergo this procedure suffer from osteoporosis. Numerous studies have shown that patients who undergo the procedure obtain substantial pain relief and improve functional status, often times to a greater extent than other surgical and nonsurgical management. Although its prevalence is low, infection after vertebral augmentation can be a serious consequence of the procedure. Blood cultures in this case were positive for Clostridium septicum. C septicum is a gram-positive, spore forming bacteria that is part of the normal gut flora in humans and is commonly associated with GI malignancy, necrosis, and inflammation. The patient did not respond to long-term intravenous antibiotics and required vertebral corpectomy and debridement with instrumentation. Vertebral body cultures obtained intraoperatively were positive for C septicum. It was noted historically that the patient had a hemorrhoidectomy 4 weeks prior to her initial fracture presentation. Although the risk of infection after vertebral augmentation is low, it is imperative that careful pre- and postoperative evaluation as well as follow-up is completed in order to prevent catastrophic consequences for patients. In patients with recent gastrointestinal tract manipulation/surgery, appropriate antibiotic prophylaxis should be considered prior to vertebral augmentation procedures.

Keywords: Case report; Clostridium septicum; Osteomyelitis; Vertebral augmentation; Vertebroplasty.

Fig. 1

T2-weighted sagittal image of the lumbar spine (Day 2) prior to vertebroplasty demonstrates a vertebral body compression fracture of superior endplate of L1 with mild height loss. There is hyperintense signal below the superior endplate within the vertebral body likely indicating a fluid-filled cleft.

Fig. 2

T2-weighted sagittal image of the lumbar spine (Day 27) postvertebroplasty of T12 (Day 9) and L1 (Day 3 & 16) demonstrates irregularity of the endplates of T12 and L1 with further height loss of L1 and obvious fluid within the T12-L1 disk space. STIR and T1-weighted images also demonstrate intense edema within these vertebral bodies.

Fig. 3

Postvertebroplasty lateral plain film radiograph of the lumbar spine (Day 26). Note the loss of disc space at T12-L1.

Fig. 4

Postvertebroplasty sagittal T1-weighted fat-saturated MRI with gadolinium contrast of the lumbar spine (Day 27). Note is made of the extensive enhancement of T12 and L1 vertebral bodies. There is also enhancing epidural extension anteriorally and posteriorally at that level. The posterior epidural extension is demarcated by the blue arrow.

Fig. 5

Postvertebroplasty sagittal STIR MRI (Day 27). Note is made of the extensive marrow edema within T12 and L1, as well as disc fluid with irregular endplates of T12 and L1.